Journal of Forensic and Legal Medicine 16 (2009) 378–380

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Journal of Forensic and Legal Medicine

journal homepage: www.elsevier .com/jflm

Clinical Practice

Survey of staff attitudes to the smoking ban in a medium secure unit

Shruti Garg MBBS MRCPsych (Specialist Trainee 4) a,Suraj Shenoy MD MRCPsych (Specialist Trainee 4) b,*,May Badee MBBS MRCPsych (Locum Consultant Psychiatrist) c,Joe Varghese MBBS MD (Senior House Officer) b,Patrick Quinn MB ChB MRCPsych (Consultant Forensic Psychiatrist) b,John Kent MB ChB FRCPsych (Consultant Forensic Psychiatrist) b

a Child and Adolescent Psychiatry, Mary Burbury Unit, East Lancashire Hospital NHS Trust, Casterton Avenue, Burnley, BB10 2PQ, United Kingdomb Yorkshire Centre for Forensic Psychiatry, South West Yorkshire Mental Health NHS Trust, Newton Lodge, Ouchthorpe Lane, Wakefield, Yorkshire WF1 3SP, United Kingdomc Newsam Centre, Leeds Partnerships NHS Foundation Trust, Seacroft Hospital, York Road, Leeds, LS14 6WB, United Kingdom

a r t i c l e i n f o

Article history:Received 18 November 2008Received in revised form 17 February 2009Accepted 2 April 2009Available online 8 May 2009

Keywords:SmokingForensicMedium secure

1752-928X/$ - see front matter � 2009 Elsevier Ltd adoi:10.1016/j.jflm.2009.04.009

* Corresponding author. Tel.: +44 7851147798; faxE-mail address: surajshenoy@hotmail.com (S. Shen

a b s t r a c t

Aims and methods: The aim of this survey was to explore staff attitudes to the indoor smoking ban in amedium secure unit and to ascertain if they had experienced any difficulties in imposing the ban inthe four months after its introduction. All staff members available on duty who agreed to participatein the survey were interviewed using a semi-structured questionnaire.Results: The response rate was 65%. Sixty-four percent of the staff supported the smoking ban. Forty-three percent reported experiencing patient management problems with the majority complaining ofincreased patient aggression, increased use of staff time in supervising patients smoking. Additionally,supervising staff were still being exposed to passive smoking. Sixty-five percent reported positive effectsdue to the ban with the majority reporting that patients were sleeping at night due to the smoking areabeing closed at night.Clinical implications: A significant proportion of the staff is still opposed to the smoking ban. Changingstaff attitudes through educational programmes will be important in ensuring success of a possible futuretotal ban in psychiatric units.

� 2009 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

1. Introduction

The smoking ban came into effect in England on 1st of July 2007to ensure that all enclosed public places and workplaces becomesmoke free. A number of publications leading up to the ban showedthat staff in psychiatric units was resistant to the proposal of thesmoking ban, with concerns mainly regarding its impact on patientbehaviour and infringement on patients’ liberties.1,2

A quarter of the British population, approximately 11 millionpeople aged 16 and over smoke cigarettes.3 The prevalence ofsmoking is considerably higher in those with mental illness andepidemiological studies have found that over 70% of patients withmental health problems smoke.4 Evidence also suggests that peo-ple with mental illness die 10–15 years earlier than the generalpopulation. A significant amount of mortality is attributed tosmoking related diseases.5 Therefore it is important that psychiat-ric hospitals are included in the general health improvement strat-egies and are not exempt from smoke-free policies.

nd Faculty of Forensic and Legal M

: +44 1924327383.oy).

The smoking ban is most pertinent to secure units as patientsare detained and are resident in these hospitals for extended peri-ods. A large majority of patients detained in these units smoke. Asurvey carried out by Meiklejohn et al. reported that 84% of all pa-tients in a medium secure unit smoked.6 The issue of smoking bansin secure hospitals was highlighted recently when a patient chal-lenged the complete smoking ban at a high secure unit. His lawyerargued that the hospital was the patient’s home and to prevent himfrom smoking there was ‘‘a disproportionate interference” with hishuman rights under Article 8 of the European Convention on Hu-man Rights, which guarantees respect for private and family life.7

Newton Lodge is a 90 bed regional medium secure unit in WestYorkshire. The partial smoking ban at Newton Lodge was imple-mented in tandem with the national ban. Prior to the introductionof the ban, there were smoking rooms for patients to use as well asbeing allowed to smoke in the courtyards and hospital grounds.Following the introduction of the ban, smoking indoors was pro-hibited and patients were permitted to smoke only in designatedoutdoor smoking areas only such as smoking shelters or the court-yard. All the seven wards in the unit have outdoor designatedsmoking areas for patients. The effectiveness of any smoking

edicine. All rights reserved.

Table 2Comparing the views of the psychiatrists with the nurses.

Question Psychiatrists (N = 12) N (%) Nurses (N = 104) N (%) Statistical test

Do you support the smoking ban?Yes 9(75) 65(62.5) P = 0.53No 3(25) 39(37.5)

Has the smoking ban caused any patient management problems?Yes 6(50) 44(31) P = 0.76No 6(50) 60(69)

Has the smoking ban had any positive effects?Yes 11(91.7) 65(62.5) P = 0.06No 1(8.3) 39(37.5)

Do you feel the ban has been successfully implemented?Yes 4(33.3) 44(31) P = 0.76No 8(66.7) 60(69)

S. Garg et al. / Journal of Forensic and Legal Medicine 16 (2009) 378–380 379

policies is determined by staff attitudes to it as they are on thefrontline and responsible for implementing it on a daily basis. Pre-vious studies have shown that staff in psychiatric settings has aless favorable attitude than general medical staff to smoke-freepolicies.8

The aim of this survey was to explore staff attitudes to thesmoking ban and to ascertain if they had experienced any difficul-ties in imposing the ban four months after its introduction.

2. Method

Over a period of three weeks in November 2007, all members ofnursing and medical staff on duty available between 9 a.m. and5 p.m. were approached to participate in the survey. Those whoagreed to participate were interviewed using a semi-structuredquestionnaire which included questions regarding staff perspec-tive on whether the ban had caused any patient managementproblems, if the ban had any positive effects and if they filled inan incident form if a patient violated the ban. They were also askedif they were smokers themselves and whether they supported theban. A copy of the questionnaire is available from the correspond-ing author on request. Data was analysed with the Statistical Pack-age for the Social Sciences (SPSS) version 11 for Windows.

3. Results

We were able to approach 116 of the 178 staff working in theunit giving us a response rate of 65%. Of those approached, 39%(N = 45) were men and 61% (N = 71) were women. The mean ageof respondents was 37(±9.62) years. Of the 116 respondents, 10%(N = 12) were doctors, 60% (N = 70) were qualified nurses and29% (N = 34) were unqualified nursing staff. 30% of all respondentswere smokers (N = 35). The number of smokers by professionalgroup is shown in Table 1. There was no statistical difference ofsmoking rates between the doctors and the nurses (p = 0.34). Therewas also no statistical difference of smoking rates between quali-fied and unqualified nursing staff (p = 0.5). Of all the respondents,64% (N = 74) supported the smoking ban in the unit. Smokers weresignificantly less likely to support the ban as compared to non-smokers (p = 0.0001).

Forty-three percent (N = 50) of the staff reported experiencingpatient management problems. Of those who reported problems,68% reported increase in patient aggression, 52% reported an in-crease in patient anxiety, 66% reported increase use of staff timein supervising patients’ smoking and 10% reported an increase inuse of as required medication by patients. There was no differencebetween smoking and non-smoking members of staff reporting pa-tient management difficulties (P = 0.09). 65% (N = 76) of staff re-ported positive effects due to the smoking ban. Of those whoreported positive effects, 51% (N = 39) felt that it had encouragedpatients to think about giving up smoking, 21% (N = 16) felt thatit had encouraged staff to think about giving up smoking, 18%(N = 14) said that smoking rooms were being used for other clinicalactivities, 23% felt that the working atmosphere was cleaner and60% (N = 46) felt that most patients were sleeping at night as des-ignated smoking areas were closed at night. 13% (N = 15) reportedfilling in an incident form if a patient violated the smoking ban,

Table 1Smoking status of respondents by professional group.

Clinical profession N Current smokers N (%)

Psychiatrists 12 2 (16.7%)Qualified nurses 70 24 (34.3%)Unqualified nurses 34 9 (26.5%)

51% (N = 60) said they would not fill in an incident form and 36%(N = 41) said that they had not encountered any incidents sincethe ban was introduced. Of all respondents, 41% (N = 48) felt thatthe ban was successfully implemented. We found no significantstatistical difference on comparing the views of the psychiatristswith the nurses (Table 2).

4. Discussion

This study suggests that almost 60% of the staff supported theindoor smoking ban in place at Newton Lodge. A survey carriedout by the Kings Fund found that only 10% of the staff in mentalhealth units supported the indoor smoking ban.1 Previous studieshave shown that staff attitudes towards supporting the ban haveimproved after its introduction.9 It was interesting to note thatthe smokers were significantly less likely to support the ban ascompared to non smokers. A third of the staff interviewed reportedpatient management problems as a result of the partial smokingban. A review of 26 international studies conducted by Lawn andPols found that increase in patient aggression was noted at psychi-atric units which imposed selective smoking bans. Ninety percentof psychiatric units which imposed complete smoking bans foundno increase in aggression or patients discharging themselvesagainst medical advice. Consistency, coordination and full adminis-trative support were found to be essential for successful imple-mentation of the ban.10

In medium secure units, supervision of patients smoking in thecourtyard is essential due to security concerns. However this studysuggests that staff time may be increasingly used to supervise pa-tients’ smoking, thus eating into time available for clinical activi-ties. One option of getting around this would be to designatesmoking breaks at fixed regular time intervals. Additionally staffsupervising patients smoking in the courtyard are still being ex-posed to passive smoking defeating one purpose of the ban.

The majority of staff felt that the ban had a positive effect on pa-tients. It was striking to note that closing the designated smokingarea at night helped many patients sleep. Anecdotal evidence sug-gested that prior to the ban many patients were sleeping duringthe day and staying up at night smoking. Other positive effectsnoted were that the working environment was cleaner and smokerooms were being used for therapeutic activities.

From this study it is evident that there are obvious problemsassociated with implementing a partial ban notably with supervis-ing staff being exposed to passive smoking. Complete smokingbans may be the only way to protect those working in psychiatricsecure units from exposure to environmental smoke given thepractical difficulties of imposing partial bans in secure units.Nearly 40% of participants in this study were opposed to the indoorsmoking ban. There may indeed be even more resistance fromstaff in psychiatric units once a complete ban comes into place.

380 S. Garg et al. / Journal of Forensic and Legal Medicine 16 (2009) 378–380

Willemsen et al. suggest conducting educational campaigns forstaff members in psychiatric institutions addressing their key con-cerns and beliefs.11 For example many feel that imposing completesmoking bans will increase agitation amongst patients but previ-ous research has shown that not to be true.

Another commonly held belief regarding patients’ human rightto smoke has to be challenged. The Human Rights Act 1998 allowsindividual choice only if that does not endanger others.12 Patient’sright to smoke has to be balanced with the employees’ right towork in a smoke-free environment. The total smoking ban is tobe implemented in psychiatric units in the near future. A consider-able amount of preparatory work needs to be done if the completesmoking ban has to be successfully implemented. Attitudes of staffwill be as important as providing smoking cessation treatments inthe long run. It would be interesting to repeat this survey once thecomplete smoking ban is in place.

Conflict of Interest

None declared.

Funding

South West Yorkshire Mental Health NHS Trust.

Ethical Approval

Ethical approval was not sought as this was a survey of staffattitudes.

Acknowledgements

We are grateful to all the health care professionals who tookpart in this survey. We would also like to thank Dr. Gerry Ro-ney, Consultant Forensic Psychiatrist, Newton Lodge for hisinput.

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